The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea

Rose Anne Indelicato, MSN, APRN-BC, PCM-BC, OCN

Disclosures

Topics in Advanced Practice Nursing eJournal. 2006;6(4) 

In This Article

Assessment of Dyspnea

One of the APN's clinical activities should include a comprehensive assessment of the patient with dyspnea. Similar to pain, dyspnea is subjective, so the patient's self report remains the foundation for the assessment whenever possible. Many of the parameters used to assess pain are also used in the assessment of dyspnea,[22] including:

  • Onset of symptom (acute vs chronic)

  • Frequency (hourly, daily, a few times per week, only when walking, etc)

  • Severity (currently, at its least, and at its worst, using an appropriate scale such as the Visual Analog Scale (VAS) or Borg -- see below)

  • Any associated symptoms (eg, cough, dizziness)

  • Exacerbating or alleviating factors (both pharmacologic and nonpharmacologic)

  • Impact on mood, activities of daily life, ability to sleep and eat

  • Meaning of symptom

  • Concerns about specific therapeutic interventions (ie, opioid analgesics and potential for substance abuse or respiratory depression)

  • Past and current treatments (including primary treatments for malignancy, over-the-counter medications, herbal supplements, etc) as well as dosing schedule, patient adherence, and side effects

The VAS, which is a valid and reliable tool, assesses symptom intensity by using a 100-mm line that can be either vertical or horizontal. Word anchors are attached to each end of the line to indicate the extremes of the sensation, with 0 representing "no breathlessness" and 100 representing "worst possible breathlessness." The patient places a mark along the line to correspond with his or her symptom intensity, and the clinician then measures the distance from the bottom of the scale (vertical) or from the left (horizontal) to the patient's mark.[1]

The modified Borg scale is a 10-point scale with descriptors anchoring the ends and specific numbers listed within the scale; it provides a valid and reliable alternative for evaluation of dyspnea severity.[23]

Most important, the APN should choose an assessment tool that the patient is able to understand, and then implement it consistently.

The APN also should be mindful of the need to clarify the language and words that patients use to describe dyspnea. Patients may use word descriptors differently due to the underlying cause of dyspnea or due to his or her cultural or ethnic background. Depending upon how the APN solicits patient responses, these variables can cause misunderstandings and lead to under-reporting and inadequate symptom management.[24,25,26]

In addition to symptom assessment, the APN must evaluate and obtain other clinical information from the patient and family in order to arrive at an appropriate treatment plan.[27,28,29,30] This subjective and objective information includes:

  • Past medical history

  • Physical examination, which may include use of accessory muscles, presence of dullness to percussion, decreased tactile fremitus, absent breath sounds, adventitious breath sounds, elevated jugular venous pressure, audible third heart sound (S3) or distant heart sounds, and pulsus paradoxus

  • Diagnostic studies such as complete blood count (CBC), serum electrolytes, chest x-ray, CT scan of chest, pulmonary function tests, sputum/bronchial cultures, arterial blood gases, blood natriuretic peptide, d-dimer, and oxygen saturation level (if appropriate to goals of care)

  • Social history

  • Smoking history

  • Advance directives, such as a healthcare proxy, living will, and wishes related to resuscitation and intubation

  • Psychological assessment, including mental status, presence and/or history of anxiety, coping styles of patient and family, meaning of symptom to patient and caregivers

  • Environmental assessment, such as the use of oxygen, need to climb stairs, distance to toilet, room temperature, air quality, appropriate use of medications, and stress of caregivers

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